Outbreak of Bilateral Endophthalmitis After Immediate Sequential Bilateral Cataract Surgery

Key Points

Question

What factors were associated with an outbreak of bilateral simultaneous endophthalmitis (BSPOE) after immediate sequential bilateral cataract surgery performed on the same day at a community-based eye clinic?

Findings

In this case series, 3 patients were diagnosed with BSPOE, with 2 of 6 eyes experiencing severe long-term consequences. Results of vitreous cultures suggested a systemic breach of sterility at the clinic.

Meaning

Because BSPOE after immediate sequential bilateral cataract surgery can have devastating consequences, adherence to strict sterile precautions are important to maintaining patient safety.

This case series investigates factors associated with an outbreak of bilateral simultaneous postoperative endophthalmitis following cataract surgery performed the same day at a single clinic.

Abstract

Importance

Since bilateral simultaneous postoperative endophthalmitis (BSPOE) after immediate sequential bilateral cataract surgery (ISBCS) can be devastating for the patient, evaluating such cases in depth is important to maintaining patient safety.

Objective

To evaluate whether a systemic breach of sterility was associated with an outbreak of BSPOE after ISBCSs performed on the same day at a single community-based eye clinic.

Design, Setting, and Participants

This retrospective case series included all patients diagnosed with BSPOE at ophthalmology departments in Denmark following an infectious outbreak after ISBCSs performed at a single community-based eye clinic in December 2022.

Exposure

Bilateral simultaneous postoperative endophthalmitis acquired after ISBCS.

Main Outcome and Measures

Patient recovery from BSPOE after ISBCS was evaluated based on clinical and microbiological reports.

Results

A woman aged 71 years, a man aged 84 years, and a woman aged 79 years consecutively presented with symptoms of endophthalmitis at regional eye departments 4 to 8 days after ISBCS performed on the same date at the same eye clinic. Five of 6 infected eyes underwent vitrectomy, and all eyes received an intravitreous injection of antibiotics. The same strain of Staphylococcus epidermidis was isolated in 4 of 5 eyes that underwent vitrectomy. Contamination of viscoelastics was ruled out with repeated cultures. One eye was eviscerated due to phthisis. In another patient, the final visual acuity of the eye most severely affected was 20/63 Snellen equivalents. Visual acuity of the remaining eyes recovered to 20/25 (3 eyes in 2 patients) and 20/20 (1 eye) Snellen equivalents.

Conclusions and Relevance

The finding of the same strain of S epidermidis in all patient cultures suggests a systemic breach of sterility at the clinic on the day of ISBCS. The outcome of these cases emphasizes the need to adhere to a strict surgical methodology and sterile principles during ISBCS.

Introduction

Bilateral simultaneous postoperative endophthalmitis (BSPOE) is a complication of immediate sequential bilateral cataract surgery (ISBCS), but few and unrelated cases have been reported.¹ Here, we describe an outbreak of BSPOE after ISBCS performed on the same day at a community-based eye clinic in Denmark.

Methods

In this case series, all patients diagnosed with BSPOE at ophthalmology departments in Denmark following an outbreak in December 2022 were included. Cases were reported to us by all Danish eye departments at the annual meeting of The Danish Society of Cataract and Refractive Surgeons, which was held 4 months later. A data processing agreement was obtained from Rigshospitalets Forskningsjura (p-2023-14210). All patients provided written and verbal consent for unrestrained investigation of their hospital records. The Appropriate Use and Reporting of Uncontrolled Case Series in the Medical Literature guidelines were followed.²

Results

Case 1

A woman aged 71 years presented with pain and blurred vision in her left eye 4 days after ISBCS. Her medical history included psychosomatic chronic pain syndrome, nephrolithiasis, psoriatic arthropathy, and normoglycemia. Visual acuity (VA) was 20/40 OD and light perception OS. The right eye had normal findings; intraocular pressure (IOP) measurement and Seidel test were not performed. The left eye had negative Seidel test results, applanation IOP of 28 mm Hg, and slight edematous cornea without infiltrates. The anterior chamber (AC) had a dense intraocular reaction (IOR), with fibrinous strands rendering the pupil invisible. No signs of nasolacrimal duct obstruction were noted. Ultrasonic B-scan of the left eye suggested vitritis, and intravitreous injections of ceftazidime, 1 mg, and vancomycin, 1.25 mg, were administered. The next day, VA was 20/63 OD, with fibrinous strands in the AC. The patient refused vancomycin for the right eye due to pain and no perceived effect in the left eye. The next day, vision had deteriorated to 20/125 OD; rebound IOP was 8 mm Hg in both eyes; and AC reaction had exacerbated in both eyes, with a 0.5-mm hypopyon in the left eye. During bilateral vitrectomy, a total retinal detachment was found in the left eye, and an abscess related to the posterior pole was suspected; the right eye showed leaking of the main corneal incision after cataract extraction. The procedures were concluded with intravitreous injections of ceftazidime and vancomycin and subconjunctival injection of cefuroxime. Postoperative treatment included Tobradex drops (Novartis), and no systemic treatment was initiated. Vitreous cultures showed Staphylococcus hemolyticus in 1 eye and Staphylococcus epidermidis and Brevundimonas species in the other, but sample laterality was not disclosed. The left eye was eviscerated 2 months later due to phthisis. The right eye recovered, with VA improving to 20/25 OD 6 weeks later and topical treatment ending after 4 additional weeks.

Case 2

A man aged 84 years presented 6 days after ISBCS with painless vision loss in both eyes. His medical history included hemicolectomy for colon cancer, pacemaker for tachycardia syndrome, atrial fibrillation, type 2 diabetes, ischemic stroke, and chronic obstructive pulmonary disease. Visual acuity was 20/100 OD and 20/200 OS, and OD and OS rebound IOP was 10 and 9 mm Hg, respectively. No Seidel testing was recorded. Both eyes had a dense IOR in the AC, with fibrinous plates covering the pupils. The left eye had a 0.5-mm hypopyon, and ultrasonic B-scan showed hyperdense elements in the vitreous. During bilateral vitrectomy, peripheral retinal hemorrhages in the right eye and extensive retinal hemorrhages in the entire left retina were seen. Surgery concluded with intravitreous injections of ceftazidime and vancomycin and subconjunctival injection of vancomycin, ceftazidime, and dexamethasone. Corneal bullae and abrasions were present at both cataract incisions in both eyes, with no description of corneal infiltrates. Chloramphenicol ointment was applied topically, and a postoperative regimen of alternating Maxidex (Novartis) and Spersadex Comp (Thea Nordic) was prescribed for both eyes. No systemic treatment was given. Vitreous cultures from both eyes showed S epidermidis, but sample laterality was not disclosed. One week postoperatively, the left eye showed vitreous hemorrhage and choroidal detachment. Both eyes gradually recovered, with VA improving to 20/20 OD 3 weeks postsurgery and 20/65 OS after 2 months. After 3 months, topical treatment was ceased.

Case 3

A woman aged 79 years presented with blurred vision and irritation in the left eye 8 days after ISBCS. She smoked daily and had a history of cerebellar infarction and fibromyalgia. Visual acuity was 20/40 OD and finger counting OS, and rebound IOP was 7 and 8 mm Hg OD and OS, respectively. A moderate IOR was seen in the AC of the right eye; no Seidel test was noted. The left eye had negative Seidel test results, dense IOR with a 0.5-mm hypopyon, fibrous strands radiating from both corneal incisions, pupillary synechiae, and secondary cataract. During vitrectomy of the left eye, punctuate hemorrhages and peripheral retinal ischemia were found in all retina quadrants, and the main cataract incision was leaking. Intravitreous injection of ceftazidime and vancomycin and subconjunctival injection of dexamethasone were given. Tobradex was prescribed in both eyes, with no systemic treatment initiated. The next day, the right eye had deteriorated and intravitreous injection of ceftazidime and vancomycin was administered, but vitrectomy was not performed. Vitreous culture showed S epidermidis. At 2.5 months, topical treatment was ended, and VA improved to 20/25 in both eyes.

In all 3 cases, genome sequencing revealed that all cultured S epidermidis species were of the same strain, which showed resistance to cefuroxime (Table). Cefuroxime is routinely used intracamerally during cataract surgery in Denmark, usually with good efficacy.

Table. Antibiotic Resistance Pattern of Vitreous Culture Isolates^a.

	Case 1			Case 2		Case 3
	Sample 1 (unknown eye)		Sample 2 (unknown eye), isolate 1, Staphylococcus hemolyticus	Sample 1 (unknown eye), isolate 1, S epidermidis	Sample 2 (unknown eye), isolate 1, S epidermidis	Only sample (left eye), isolate 1, S epidermidis
	Isolate 1, Staphylococcus epidermidis	Isolate 2, Brevundimonas species
Ceftazidimeb	NT	R	NT	NT	NT	NT
Cefuroximeb	R	NT	NT	R	R	R
Vancomycinb	S	NT	S	S	S	S
Ampicillin	R	NT	NT	NT	NT	R
Chloramphenicol	NT	NT	NT	S	S	NT
Ciprofloxacin	NT	R	NT	NT	NT	NT
Clindamycin	S	NT	S	S	S	S
Dicloxacillin	R	NT	R	R	R	R
Erythromycin	S	NT	S	S	S	S
Fosfomycin	NT	NT	NT	S	S	NT
Fucidin	R	NT	S	R	R	R
Linezolid	S	NT	S	S	S	S
Meropenem	NT	S	NT	NT	NT	NT
Moxifloxacin	R	NT	S	R	R	R
Penicillin	R	NT	R	NT	NT	R
Piperacillin or tazobactam	NT	S	NT	NT	NT	NT
Rifampicin	S	NT	S	S	S	S
Tobramycin	NT	S	NT	NT	NT	NT
Trimethoprim or sulfamethoxazole	NT	NT	NT	S	S	NT

Abbreviations: NT, not tested; R, resistant; S, sensitive.

^a All cultured S epidermidis was of the same genomic strain. Information of sample laterality had been lost in microbiological reports. There was uncertainty whether antibiotic treatment had covered both cultures isolated in 1 eye (case 1, sample 1) in the patient who later lost an eye to phthisis.

^b Antibiotics that had presumably been administered during ISBCSs at the community-based eye clinic (cefuroxime) or had definitely been administered at treating ophthalmology departments (ceftazidime and vancomycin).

Discussion

In this outbreak of BSPOE after ISBCS performed on the same day at the same clinic, all patient vitreous cultures showed S epidermidis in 1 or both eyes. No eyes showed clear evidence of leakage before vitrectomy, and low IOP values across eyes may have been associated with capillary shutdown secondary to endophthalmitis rather than suboptimal cataract incision architecture. All cultured S epidermidis species were of the same cefuroxime-resistant strain. For unknown reasons, sample laterality was not available in the microbiological reports, but additional antibiotic treatment likely could not have saved the eye lost to phthisis.

The reason for the outbreak remains unclear. Contaminated ophthalmic viscosurgical devices (OVDs) were suspected, but repeated cultures of new OVD packages from the same batch did not support this, and other clinics using the same batch did not experience endophthalmitis. Thus, a systemic breach of sterility is suggested.

Bilateral simultaneous endophthalmitisafter ISBCS is very rare. A systematic review found only 9 unrelated cases reported in the past 50 years.¹ A review of 46 119 ISBCS sessions in Sweden found a BSPOE rate after ISBCS of 0.0022%.³ In 6 of the 9 previously reported cases, the surgical protocol recommended by the International Society of Bilateral Cataract Surgeons was breached or uncertain.^4,5,6,7,8 Breaches included use of the same instruments, fluids, or OVDs for both eyes^4,5,6; lack or uncertain use of intracamerally injected antibiotics^4,5,6,8,9; and no use of sterile indicators in the autoclave cycle.⁷ The 3 cases with no recorded breach of sterility included 1 older individual in poor health who died shortly after ISBCS,³ 1 immunocompromised patient who received intracameral moxifloxacin in inadequate doses,¹ and 1 patient presumably exposed to unsafe ventilation in the operating room.^1,10

Limitations

Details of ISBCSs and intraoperative devices or sterility procedures used were not available, and investigation by authorities did not find a contamination source. We encourage surgeons to share as much information as possible with investigators to identify factors that could improve patient safety.

Conclusions

This case series describes an outbreak of BSPOE after ISBCS with devastating consequences in 2 of 6 eyes. All patients recovered good visual function in at least 1 eye. Because of its numerous benefits, including rapid visual rehabilitation with avoidance of intersurgical anisometropia, reduced health care costs, few postoperative visits, and short travel distance and time for patients,¹¹ we believe that ISBCS is safe with strict adherence to guideline-recommended precautions.^12,13

Supplement.

Data Sharing Statement